Urogenital Flashcards
diagnosing scrotal masses
- can you get above it?
- is it separate from the testis?
- cystic or solid?
what is it if you can’t get above a scrotal mass
inguinoscrotal hernia
hydrocele extending proximally
what is a separate and cystic scrotal mass
epididymal cyst
what is a separate and solid scrotal mass
epididymitis / varicocele
what is a testicular and cystic scrotal mass
hydrocele
what is a testicular and solid scrotal mass
tumour, haematocele, granuloma, orchitis
what is an epididymal cyst and what is it caused by
- benign cyst lesion of the epididymis
- possibly from obstruction of the epididymis
clinical manifestations of epididymal cyst
- small paratesticular swelling
- tender
- thin-walled, translucent cystic lesion
what is the management of epididymal cyst
- remove if symptomatic
what is a hydrocele
- an abnormal accumulation of fluid in the space between the two layers of the tunica vaginalis
causes of hydrocele
primary cause = trauma
secondary cause = reaction to underlying pathology (epididymitis, orchitis, tumour)
clinical manifestations of a hydrocele
- scrotal swelling
management of a hydrocele
- can resolve spontaneously
- aspiration
- surgery = placating the tunica vaginalis/ inverting the sac
what is a varicocele
a persistent abnormal dilation of the pampiniform venous plexus in the spermatic cord
clinical manifestations of a varicocele
- nodularity on the lateral side of the scrotum
- dull ache (worse after prolonged standing)
- male subfertility (increased blood flow raises temp and impairs spermatogenesis)
management of varicocele
surgery to remove
if untreated can lead to infertility
what is an adenomatoid tumour
- most common benign paratesticular neoplasm
- small, solid, grey/white tumours <3cm
where do adenomatoid tumours occur
epididymis, spermatic cord, tunica albuginea
causes of urinary tract obstruction
urinary stones urothelial tumours extrinsic compression prostatic hyperplasia urinary tract malformations strictures
clinical manifestations of acute upper tract obstruction
ureteric colic (pain radiates to groin)
superimposes infection
enlarged kidney
clinical manifestations of chronic upper tract obstruction
flank pain, renal failure, superimposed infection,
clinical manifestations of acute lower tract obstruction
acute urinary retention, severe suprapubic pain, acute confusion
clinical manifestations of chronic lower tract obstruction
urinary frequency, hesitancy, poor stream, terminal dribbling, overflow incontinence
investigations for urinary tract obstruction
- bloods (U&E, FBC, creatinine, PSA)
- urine dipstick and MC&S
- US = hydronephritis (swelling of kidney) or hydroureter
- CT = level of obstruction
treatment of urinary tract obstruction
- upper = nephrostomy or ureteric stent
- lower = urethral or suprapubic catheter
complications of urinary tract obstruction
-risk of infection, stone formation, renal damage
what can cause haematuria
- malignancy
- calculi
- IgA nephropathy
- polycystic kidney disease
management of haematuria
- urological assessment, imaging, cystoscopy to exclude malignancy and calculi
- renal referral
clinical manifestation of testicular torsion
- sudden onset pain in one testis and abdomen
- nausea and vomiting common
- tender, hot, swollen testicle
- testis may lie high and transversely
differential diagnosis for testicular torsion
- epididymo-orchitis = symptoms of urinary infection and more gradual onset of pain
investigations for testicular torsion
- doppler US = lack of blood flow to a testicle
- do not delay surgical exploration
management of testicular torsion
- possible orchidectomy + bilateral fixation
- surgery to expose and untwist the testis
what is benign prostatic hyperplasia
- enlargement of the prostate gland due to an increase in cell number
pathology of BPH
- increased levels of dihydrotestosterone in prostate (androgen)
- increased oestrogen levels in blood induce androgen receptors in prostate tissue and stimulate hyperplasia
clinical manifestations of BPH
- LUTS = frequency, urgency, nocturia, hesitancy, poor flow, terminal dribbling
differential diagnoses of BPH
- overactive bladder, prostatitis, prostate cancer, UTI
investigations for BPH
- U&E
- US
- PSA test
- biopsy
management for BPH
- lifestyle = avoid caffeine and alcohol. void twice in a row
- drugs = tamsulosin (alpha-blockers)
- surgery = transurethral resection or incision of prostate, retropubic prostatectomy
complications of BPH
- urinary retention
- recurrent UTI
- bladder stones
- obstructive nephropathy
what is a renal carcinoma
malignant epithelial neoplasm arising in the kidney
clinical manifestations of renal carcinoma
- half present with painless haematuria
- picked up incidentally on imaging
- small proportion present with metastatic disease
- loin pain, abdo mass, anorexia, weight loss, malaise.
investigations for renal carcinoma
- hypertension from renin secretion
- FBC = polycythaemia from erythropoietin secretion
- ESR, U&E, ALP
- urine = RBCs
- US, CT/MRI, CXR
management of renal carcinoma
- radical nephrectomy
- cryotherapy and radiofrequency ablation if not fit for surgery
what is a nephroblastoma - Wilm’s tumour
- malignant childhood renal neoplasm
- abdominal mass and haematuria
- most low stage with good prognosis
what is a urothelial carcinoma (bladder transitional cell carcinoma)
- a group of urothelial neoplasms arising in the urothelial tract
clinical manifestations of urothelial carcinoma
- painless haematuria
- LUTS
- recurrent UTI
- voiding irritability
investigations for urothelial carcinoma (bladder cancer)
- urine cytology
- IVU
- cystoscopy and biopsy
- CT/ MRI
management of urothelial carcinoma (bladder cancer)
- Tis/Ta/T1 (80% of patients) = transurethral cystoscopy/resection of bladder tumour
- T2-3 = radical cystectomy (radiotherapy if need to preserve the bladder)
- T4 = palliative chemo/radiotherapy, chronic catheterisation and urinary diversions
what is prostate carcinoma
malignant epithelial tumour arising in the prostate
pathology of prostate cancer
- arise from precursor lesion (prostatic intraepithelial neoplasia) with neoplastic transformation of the epithelium lining of the prostatic ducts and acini.
- mutations in a number of genes
clinical manifestations of prostate cancer
- asymptomatic
- LUTS
- symptoms of metastatic disease
investigations for prostate cancer
- often diagnosed through needle biopsy to investigate raised serum PSA
- DRE = hard, irregular prostate
- increased PSA levels
- biopsy
management of prostate cancer
- prostatectomy
- radiotherapy
- analgesia
- treat hypercalcaemia
what are the two testicular tumours
- seminoma = germ cell tumour of the testicle
- teratoma = non-germ cell tumour of the testicle
clinical manifestations of testicular tumour
- painless testis lump after trauma/infection
- secondary hydrocele
- pain
- dyspnoea
- abdo mass
differential diagnosis of testicular tumour
- hydrocele
- abdominal hernias
- orchitis
investigations for testicular tumours
- CXR
- CT
- excision biopsy
- alpha-FP and beta-hcg useful tumour markers to monitor treatment
tumour staging of testicular tumours (1-4)
- no evidence of metastasis
- infradiaphragmatic node involvement
- supradiaphragmatic node involvement
- lung involvement (haematogenous spread)
management of testicular tumours
- radical orchidectomy
- seminomas are very radiosensitive
- chemo = teratoma
- radiotherapy = seminoma
what is urolithiasis - urinary tract calculi (nephrolithiasis)
- formation of stony concretions in the bladder or urinary tract
pathology of urolithiasis
- calculi form leading to blockage and abrasing structures.
- renal stones = crystal aggregates, form in collecting ducts and deposit anywhere from renal pelvis to urethra
where are renal stones classically deposited (3)
- pelviureteric junction
- pelvic brim
- vesicoureteric junction
risk factors for renal stones/ urolithiasis
- high protein/ salt intake
- male, white
- obesity
- dehydration
- meds = antacids, carbonic anhydrase inhibitor
- crystal urea
- increase in urinary solutes (calcium, uric acid, oxalate, sodium) and a decrease in stone inhibitors (citrate, magnesium)
what can renal stones be formed from
- calcium oxalate/ calcium phosphate (hyperparathyroidism, excess dietary calcium, primary renal disease)
- magnesium ammonium phosphate
- uric acid (hyperuricaemia, dehydration)
- struvite (chronic UTI)
- cystine stones
what are urinary calculi
- renal stones
- crystal aggregates which form in the renal collecting ducts and become deposited in the urinary tract
what are triple stones
- result of infections (eg proteus) that produce the enzyme urease which splits urea to ammonia
presentation of renal stones
- fever, vomiting, flank pain
- most asymptomatic
- stones causing obstruction lead to hydronephritis (obstruction + dilation of renal pelvis causing lasting damage)
- larger stones tend to remain confined to the kidney
- smaller stones tend to pass into ureter and and become impacted causing ureteric colic
- infection, haematuria, proteinuria, sterile pyuria
where is pain felt for obstruction of the kidney, mid-ureter, lower ureter and bladder/urethra?
- kidney = felt in loin
- mid-ureter = mimic appendicitis
- lower ureter = bladder irritability and pain in scrotum, penile tip or labia majora
investigations for renal stones
CT = gold standard
- Xray to detect kidney stones
- urine dipstick = blood
- 24h urine sample for stone biochemistry
- US = hydronephrosis
acute management of renal stones/urolithiasis
- NSAIDs for pain
- antiemetics for vomiting and nausea
- allow stones <5mm to pass spontaneously
- IV fluids
surgical management of renal stones/ urolithiasis
- percutaneous nephrostomy (drain urine straight from kidney = symptom relief)
- ureteric stent
- percutaneous nephrolithotomy = remove stone from the kidney by small puncture of skin
- endoscopic/open surgery to break down stone
- extracorporeal shock wave lithotripsy = uses shock waves to break down stones so fragments can be passed
prevention of renal stones
- overhydration
- low salt diet
- normal dairy intake
- healthy protein intake
- reduce BMI
- active lifestyle
lower urinary tract infections
- cystitis
- prostatitis
- epididymitis/ orchitis
- urethritis
upper urinary tract infections
pyelonephritis
classification of urinary tract infections
- asymptomatic bacteriuria
- uncomplicated (normal renal structure and function)
- complicated (structural/ functional abnormality)
what is the main pathogen that causes UTI
Escherichia coli
why are omen more susceptible to UTI
shorter urethra so closer proximity to anus
presentation of cystitis (bladder infection)
- frequency, urgency, dysuria, haematuria, suprapubic pain
what is the presentation of ascending spread to the kidneys (acute pyelonephritis)
- more severe
- fever, rigors, vomiting, loin pain
diagnosis of UTI
- urinalysis = leucocytes or nitrates = quick screening test
- look for protein, blood, pH, ketones, glucose, leucocytes an nitrates
- microscopy = WBCs, RBCs, casts and bacteria
- microbiological culture (midstream specimen)
management of uncomplicated UTI
- Abx for 3 days
- if fails then culture urine and treat according to Abx sensitivity
management of UTI in men
- lower UTI with 7 day Abx course
- if prostatitis then give a course of ciprofloxacin (able to penetrate prostatic fluid)
management of complicated UTI
7day Abx
management of UTI in pregnant women
- asymptomatic bacteriuria should be confirmed on a second sample
- Abx
what is prostatitis
- inflammation/swelling of the prostate gland
- ascending infection from the urinary tract or haematogenous spread
clinical presentation of prostatitis
pain = perineum, rectum, scrotum, penis, bladder, lower back
- fever
- malaise
- nausea
- urinary symptoms
treatment of acute prostatitis
- Abx treatment for 28days immediately
- treat pain
treatment of chronic prostatitis
- pain relief
- stool softener
- Abx 4-6 weeks
what is cystitis
- inflammation of the bladder caused by bladder infection (UTI, E.coli)
symptoms of cystitis
- frequency, dysuria, urgency, suprapubic pain, polyuria, haematuria
what is pyelonephritis
infection of the renal parenchyma and soft tissues of the renal pelvis/ upper ureter
symptoms of pyelonephritis
- loin pain, fever, pyuria (puss in urine)
- vomiting
- cystitis symptoms
- septic shock
investigations for pyelonephritis
- abdo examination = tender loin
- bloods and cultures
- US scan to rule out upper tract obstruction
treatment of pyelonephritis
- fluid replacement
- broad spec IV Abx (c-amoxiclav)
- drain obstructed kidney
- analgesia
what is urethritis
inflammation of the urethra
pathology of urethritis
- mostly sexually transmitted
- gonorrhoea
- chlamydia trachomatis
- needs sexual health referral
treatment of urethritis
- depends on cause
- gonorrhoea = ceftriaxone
- bacteria = oflaxacin
- chlamydia = doxycycline
presentation of urethritis
- painful/difficult urination
what is epididymo-orchitis
inflammation of the epididymis +/- testes
causes of epididymo-orchitis
- chlamydia
- e.coli
- mumps
- n.gonorrhoea
pathology of epididymo-orchitis
- sexually transmitted infection ascending from the urethra or non-sexually transmitted uropathogens spreading from urinary tract
features of epididymo-orchitis
- sudden onset tender swelling, dysuria, fever, urethral discharge
- possible infertility
- symptoms way worsen before improving
treatment of epididymo-orchitis
- doxycycline
- sexual abstinence and contact tracing
- analgesia and drainage of any abscess
genital ulcers
- HSV
- flu-like prodrome, vesicles/papules around genitals, anus, throat = burst forming shallow ulcers
- urethral discharge, dysuria, urinary retention, proctitis
- diagnosis via PCR
treatment of genital ulcers
- analgesia = topical lidocaine
syphilis
- any genital ulcer is syphilis until proven otherwise
- primary= genital skin, nipples, mouth
- secondary = onset after infection, skin rash
- incubation 9-90 days (usually 21-35 days)
diagnosis of syphilis
- PCR
- early moist lesions
- serology
treatment of syphilis
- penicillin injection
- follow up and partner notification essential
chlamydia diagnosis
- nucleic acid amplification test (NAAT)
- male = first void urine
- female = vaginal swab, first void urine, endocervical swab
chlamydia treatment
- partner management
- doxycycline or azithromycin for 7 days
- community screening
gonorrhoea diagnosis
- microscopy of gram stained smears of genital secretions look for gram negative diplococci within cytoplasm (male urethra, female endocervix, rectum)
- culture on selective medium
- sensitivity testing
- NAAT
gonorrhoea treatment
- surveillance of Abx sensitivities
- ceftriaxone with azithromycin
